27/11/2025
⚠️ DIGOXIN: THE DOSE THAT CAN TRICK ANYONE
Recently there was an order for digoxin where the dose didn’t look right.
Just one decimal point off… but that tiny difference would have given the patient almost 10 times the intended amount.
It reminded me how easy it is to misread mcg vs mg especially on a busy day.
Digoxin is powerful but there’s zero room for dosing errors:
• 62.5 mcg ≠ 0.625 mg
• 0.0625 mg = 62.5 mcg
Because the therapeutic window is so narrow, even small mistakes can lead to:
• nausea, vomiting
• yellow/green vision
• bradycardia
• dangerous arrhythmias
Thankfully that case was caught early.
Pharmacists, nurses, doctors, let’s stay alert with this one.
Decimals matter. Dose carefully. ❤️